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Thinking Outside the Box: Value-Based Emergency Care

A plan by the college's recently convened think tank, the Task Force for Value-Based Emergency Care, spells out a strategy for becoming part of the health care reform now inching toward becoming federal law.

“The idea was to try to put together a blueprint for the new world order of value-based world payment policy,” explained Dennis Beck, MD, a task force chair. Like the rest of the country, “emergency medicine is trying to get its arms around this,” said Dr. Beck, the president and chief executive officer of Beacon Medical Services in Aurora, CO.

Health care delivery and compensation has been the target of revision by several presidential administrations for the past 75 years, starting with President Harry Truman just after World War II. The current push for health care reform seems destined for a more comprehensive outcome, even in the face of significant opposition. “…U.S. history is studded with major policy changes that were not politically feasible — until they were,” noted Stanford economist Victor Fuchs, PhD, in a New England Journal of Medicine perspective. (2009;360[3]:208.)

One aspect of the reform proposal winning support so far is the concept of the medical home. As the 24-hour-a-day, seven-day-a-week safety net, emergency care needs to be a “room within that medical home,” Dr. Beck said. Determining how emergency care can coordinate with other providers to reduce readmission and overuse of imaging and other testing is one way emergency medicine fits into the proposed system, he said.

The strategy for that? Close, direct contact by emergency departments with medical homes and possibly with HRSA Federally Qualified Health Centers, according to the framework of the task force plan. It lays out the possibility of a predicted payment for certain complaint-driven ED episodes, which would be based on evidence-informed guidelines.

It also contains a provision for incentives, meeting certain quality and resource-use parameters to generate additional compensation for providers and hospitals, Dr. Beck said. But, “you'd have to develop the tools for this,” he added. That would mean inclusion of patient-specific risk adjustments, factors ranging from the presence of comorbidities to socioeconomic status and possibly differences in regional parameters. The plan concludes that there is a critical need to find ways to mesh emergency medicine with the quality measures, value-based purchasing, and payment-reform initiatives, which are a proposed bulk of the reform package before Congress.

In October, the ACEP board of directors accepted the task force report from Dr. Beck and Bruce Auerbach, MD, also a task force chair and the vice president and chief of emergency and ambulatory services at Sturdy Memorial Hospital in Attleboro, MA. As this article went to press, the board was slated to decide which components they wanted further defined or implemented, although there seemed to be no disagreement over the main focus areas: how coordination of care can take place with medical homes, ways in which ED encounters constitute health care episodes, the potential for developing complaint-based, risk-adjusted episodes of care, the possibility of partnering with HRSA Federally Qualified Health Centers, and the feasibility of establishing an emergency medicine data registry for quality improvement and reporting.